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Termination/Abortion Flashcards

1
Q

How many pregnancies are result in abortion?

A

19%

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2
Q

What age range is highest for abortions?

A

20-24yo

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3
Q

When are abortions performed the most?

A

First trimester

63% <8wks

91% <13wks

Only 9% are after that

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4
Q

When is the legal limit for a 2nd trimester abortion in California?

A

23wks & 6days

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5
Q

Roe vs Wade

A

1st trimester (up to 14wks)

  • The state can’t interfere with a woman’s right to choose
  • decision b/w her & her provider
2nd trimester (14-24wks)
- The state CAN regulate abortion procedures fro safety reasons
3rd trimester ( >24wks)
- The state CAN prohibit abortions except when necessary
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6
Q

Hyde amendment

A

Forbids the use of federal funds for abortions except for Incest or life endangerment

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7
Q

What kind of restrictive laws are out there?

A
  • waiting periods
  • mandatory counseling
  • parental consent/notification
  • can’t be covered by private insurance
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8
Q

What is the leading research & policy organization committed to advancing sexual & reproductive health & rights in the US & globally?

A

Gutttmacher Institute

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9
Q

What are some falsehoods surrounding abortion?

A
  • long term mental health consequences
  • fetus feels pain
  • link to breast cancer
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10
Q

Random stuff

A
  • 51% of OBGYN residents are trained to do this
  • 32% of med schools offer 1 abortion lecture
  • complication rate lower than wisdom tooth removal overall
  • 2nd trimester abortions assoc w/ increased morbidity & mortality
    • maybe more social/emotional challenges
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11
Q

Describe pregnancy counseling

A
  • Be clear about the results: Test is positive, you’re pregnant
  • Allow time for pt to process
  • Don’t assume how pt will react
  • give basic information, non-directive
  • referL adoption, abortion, prenatal
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12
Q

What is involved in pregnancy dating & confirmation of IUP?

A
  1. LMP
  2. Quart Hcg
  3. Bimanual exam (fruit comparison)
    • lemon = 5-6wks
    • medium lemon = 7-8wks
    • grapefruit = 9-10wks
    • uterus out of pelvis @ 12wks
    • umbilicus = 20wks
  4. Ultrasound
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13
Q

What characteristics are involved w/ the Transvaginal probe

A
  1. Empty Bladder*
  2. Detects Earlier pregnancy*
  3. Better RESOLUTION , LESS DEPTH*
  4. More invasive*
  5. Probe 7.5-10mHz*
  6. Discriminatory level 1800-2300mIU/ml
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14
Q

What are the characteristics of a Transabdominal Probe?

A
  1. Full bladder*
  2. BETTER DEPTH, LESS RESOLUTION*
  3. Hard to see if <6wks*
  4. Less invasive*
  5. Probe 3-5mHz*
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15
Q

How to Locate an IUP

A

Measure 3 dimensions in 2 planes

  • longitudinal/length & Ht
  • transverse plane: width

Calculate the Mean Sac Diameter (MSD)
- MSD = L+W+H)/3

Calculate GA
- GA in days = MSD +30

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16
Q

What’s the diagnosis for a non-viable pregnancy?

A

Empty GS >25mm diameter

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17
Q

Early Preg Confirmation

Does not exclude ectopic

A

F: fundal, mid/upper uterus

E: elliptical/round in 2 views

E: Eccentric to the endometrial stripe

D: Decidual reaction (fluffy white cloud/ring around the sac

S: Size >4mm (soft criteria)

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18
Q

Other features of an IUP

A
  • yolk sac
  • BPD
  • CRL
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19
Q

What is the first US finding that confirms an IUP?

A

Yolk sac

  • round, echoic ring w/anechoic (dark center) inside the GS
  • Appears 5-6wks
  • MSD (mean sac diameter) = 5-10mm
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20
Q

When can cardiac activity be visualized on U/S?

A

Around 6 1/2wks

  • usually not assessed until 8wks at first prenatal visit
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21
Q

How to measure CRL

A

CRL = fetal pole

  • long axis (no limbs)
  • Calculate GA: CRL +42days
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22
Q

BPD measurement

A

> 12-14wks

  • inside to outside the skull
  • at level of the thalamus
  • No unchallenged/eye structures
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23
Q

When can you get a MAB?

A

10wks

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24
Q

When can you get a surgical abortion?

A

Before 13wks 6days

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25
What is MAB?
Medical abortion (chemical) Using medications NOT surgery Mifepristone & Misoprostol (Cytotec)
26
What are the benefits of MAB?
- Can be done at home - sense of control over the process - safe & effective up to 70days
27
Risks of MAB
- Endometritis, infxn, hemorrhage (same as surgical) - teratogenic to ongoing pregnancy (so don’t change your mind) - may still need surgical aspiration
28
Indications for MAB/1st trimester abortion
Mifepristone approved up to 49d (10wks) Off-label after this
29
Contraindications of MAB
1. Ectopic pregnancy 2. IUD — take it out first 3. Chronic adrenal Faillure/Long term steroid therapy 4. Hemorrhagic disorders, Anticoagulants 5. Porphyrias (disorder from build up from blood products) 6. Non-compliance 7. Maybe chronic conditions like: HTN,DM, renal/hepatic/CV/cig smoking
30
What are the clinician requirements for MAB?
* Mifepristone Can only be prescribed by physicians BUT they can delegate another healthcare professional to administer the drug - make accurate assessment of GA - diagnose ectopic - surgical intervention if bleeding/incomplete abortion or make plans for care w/another provider - assure access to a hospital where they can get transfusions/resuscitation
31
Clinician requirements (continued)
- sign prescriber agreement w/ manufacturer of mifepristone - require pts read manufacturer’s medication guide & sign Pt agreement form - report - ongoing preg - serious events (hospitalization, infxn, bld transfusion
32
What are the 2 regimens?
1. FDA approved, manufacturer recommended - Mifepristone 600mg PO (—48hrs—> Misoprostol 400mcg PO - both given by physician so pt has to come back *Not as effective 2. Alternative regimen = evidence based - Mifepristone 200mg PO by clinician—24-72hrs--> Misoprostol 800mcg Buccal clinician or pt *Most effective/cheaper
33
Benefits of Evidence based Regimen
- fewer ongoing pregnancies - cheaper - Fewer side effects - Convenience - greater efficacy: 50-63day gestation (7-9wks)
34
How does Mifepristone work?
Antiprogestin - binds to progesterone receptors with greater affinity than progesterone itself - blocks action needed for placental attachment
35
Initial visit
1. Confirm pregnancy & GA - GA:LMP, Transvaginal U/S & Pelvic exam - Preg: serum/urine Hcg or U/S - U/S to r/o ectopic 2. Counsel about options & Informed consent 3. STI testing 4. Blood typing/verification + RhoGAM 5. Prophylactic abx to prevent endometritis 6. Mifepristone given 7. F/U
36
What Abx are used for MAB prophylaxis ?
Azithromycin 500mg x 1 - can cause prolonged QT syndrome Doxycycline 100mg BID x7days
37
What are some side effects of Mifepristone?
1. GI: n/v/d 2. Abd pain & cramps 3. Excessive vaginally bleeding, 8-17d 4. HA, dizziness, fatigue
38
Pt education
- written & verbal instructions about sxs, adverse effects and what to do if significant pain, bleeding - NSAID/narcotic analgesia - Emergency phone numbers given - how to take it
39
Follow Up visit
2wks - to confirm expulsion - via pelvic exam, Hx, or transvaginal ultrasound - provide contraception
40
What are some Complications of MAB?
- Hemorrhage (may need to r/o if incomplete) - Infxn 0.016% - Incomplete abortion - incomplete expulsion - ongoing pregnancy - unrecognized ectopic pregnancy
41
Should get an eval if
- fever, chills, body aches - excessive/prolonged bleeding - moderate -severe pelvic pain more than a day after expulsion - purulent vaginal discharge
42
What determines efficacy of MAB?
1. Gestational duration (49-70days/7-10wks) 2. Route of administration & does of MISOPROSTOL 3. Parity - rate of success lower with increasing parity & if had one before
43
What is the most commonly used method of pregnancy termination in the U.S.?
Surgical abortion/TAB
44
What are the techniques of TAB?
- D&E - sharp cutterage - suction cutterage
45
When is TAB performed?
7wks-12/13wks 6days
46
What are the benefits of a TAB/surgical abortion?
- 1 visit only - safe & effective for FIRST TRIMESTER abortions - complication rate 0-3% - 98-99 % effective
47
Risks of surgical abortion/TAB
1. Endometritis 2. Life threatening infections (more w/ TABs) 3. Hemorrhage - d/t cervical laceration or uterine injury (instrumentation)
48
What are the indications for TAB?
1. (VEA)- very early abortion - up to 6wks after +preg test - NO visualization of sac required if ectopic unlikely - manual vacuum/electric aspiration - tissue examined while pt in room - serial Hcg testing done if not confirmed
49
TAB initial visit
1. Confirm pregnancy & GA 2. Counsel about options & informed consent 3. STI testing 4. Contraception counseling 5. Bld typing + RhoGAM 6. Pre-dose w/ NSAID, anxiolytics, and prophylactic Abx - Ibuprofen + Ativan 7. Sterile technique 8. Products of conception verified while pt in room 9. Post-op monitoring 30min 10. D/C with meds: NSAIDS, Methergine, Doxycycline & contraception 11. F/U in 2-4wks
50
What are the return precautions for TAB?
If sxs have not resolved within 1wk or if normal menses has not returned in 6wks - no sex/tampons for 2wks - most complications happen within a wk
51
What are possible complications of a TAB?
1. Hemorrhage - retained tissue - uterine perforation - retained tissue - uterine atony 2. infxn 3. Incomplete abortion
52
Indications for 2nd trimester abortions
Elective pregnancy termination - Delay in dx or obtaining abortion Fetal anomaly Maternal illness (severe preeclampsia) PROM
53
Protocol of 2nd trimester abortions
Preprocedure prep - dilate cervix w/ Laminaría Anesthesia/Abx - paracervicla block/IV conscious sedation Procedure (focusing on D&E) Utterotonics Assessment of retaine dproducts Discharge F/U in 2wks
54
Complications of 2nd trimester abortions
``` Retained products of conception Cervical laceration Uterine perforation Infxn Hemorrhage ```
55
What are the most common signs of early pregnancy loss?
``` Vaginal bleeding Abd cramping Pelvic/back pain Passing tissue Constitutional: fever, chills, muscle aches ```
56
Diagnoses of early pregnancy loss
* One of the following: 1. US confirmation of embryonic gestation or fetal demise in uterus w/ falling Hcg levels 2. Absence of previously seen IUP on US 3. Tissue exam confirming expulsion
57
EPL Management
1. Expectant- watch & wait 2. Medical mgt - MAB meds: Mifepristone+ Miso or just Miso - Methotrexate if ectopic - Need to F/U with Ultrasound 3. Aspiration: no F/U
58
What should ALWAYS be considered w/ First trimester bleeding?
Ectopic pregnancy 6-8wks
59
How is ectopic pregnancy diagnoses confirmed?
Serial HCGs & Ultrasounds
60
What should be suspected with a + preg test w/o US evidence?
Ectopic
61
What is the treatment for ectopic preg?
Methotrexate w/ serial Hcg levels
62
LMP should be considered a vital sign for which age group?
9-55yo

Obstetrics (6 decks)

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